Scalpel or Sword?

Pause

2009-08-24T05:10:00.005-05:00

Med Glossary, Part 5

2009-08-18T13:40:00.000-05:00

"I thought nothing of it."

As in, "I had this pain that shot up from my hip bone to my left ear, and I thought nothing of it, but then I got this tingly sensation in my right pinky so I decided I'd better go to the ER."

What he really means is,

1) I've been worrying about that 5 second pain constantly ever since it happened. And see how swollen my hands are? And what is this coating on my tongue?

2) My auntie just had a stroke, and I don't want to die. The doctor told her there was nothing wrong with her too.

3) On the internet I read that shooting pains on the left side can be signs of a heart attack.

4) I'm out of my Xanax. I fired my doctor last month and he won't refill it.

5) This is labor day weekend, and I have plans. Can I get a work excuse?

Have a great holiday, everybody!

Previous glossary entries here.

My Take on the Health Care Crisis - Part 1

2009-08-06T05:10:00.002-05:00

Originally posted almost two years ago, here is my take on the healthcare crisis, the four parts presented in order below. Enjoy!

Here are the two major problems with our current health care system that have everyone in a tizzy:

1) The poor folks in America have limited access to health care services

2) Health insurance (and American medical care in general) costs too much

First, let's get something straight: anyone who is honest and who has even the most basic level of medical knowledge should admit that the quality of healthcare in America is the best in the world. Rich people didn't get that way by being stupid, so when they get cancer they aren't flying to Europe or Canada to get treated....they are going to MD Anderson or the Mayo Clinic.

The same thing can be said about heart disease, diabetes, musculoskeletal disorders, or any other medical problem you can think of: America treats these conditions better than anyone else in the world. When a multimillionaire pro athlete needs a complicated operation to save his career, he turns to American surgeons. When a wealthy foreign dignitary needs a heart bypass, he comes to America. Say it again, repeating as often as necessary until it sinks in: America provides the highest quality medical care in the world.

We also have the best medical training in the world. Physicians from other countries are lined up at our gates, hoping against all odds that they might be accepted into any one of our residency training programs. Only the best will be accepted. Our physicians accept training positions in other countries only as a last resort, because for the most part they are well-known to be inferior.

Of course we also have the best medical technology in the world. We have more advanced medical technology concentrated in 1000 acres in Houston than most other nations can even dream of. Do you really think the average Cuban is likely to get an insulin pump or an LVAD? How about a liver transplant?

Because we have the best physicians, the best medical training, and the best medical technology in the world, we also do some of the most important medical research in the world. Wealth begets wealth.

So why does American health care cost so much? Because it is the best. Why do our poor people have limited access to health care? Because they can't afford it. If we gave it all away, we wouldn't have the best quality healthcare anymore. Other countries ration healthcare by making everyone wait for it equally. That's why wealthy Canadians fly down here to get their hips replaced and upper-class Brits fly over here to get treatment for their breast cancer. They don't want to wait. We ration care by limiting access to those who can't pay for it.

Don't misunderstand and don't buy the baloney the frantic lefties are trying to feed you....poor people in this country still get better care than in any other country. I admitted a penniless patient with bowel obstruction from his colon cancer just last week, and an uninsured man with a large brain tumor last month. Both got the highest quality surgery the world has to offer the very next day.

Yes there are barriers to care for the poor. These people couldn't just walk into the Mayo Clinic and ask for a PET scan. And they will still get a huge bill they will be unable to pay. But they will ultimately get the care they need, thanks to EMTALA.

But our current system is unsustainable over time, as more people discover the EMTALA loophole and the willingness (and ability) of the insured to pay for the care of the uninsured gets stretched to the breaking point. So what is my solution? Stay tuned.

Part 2

Part 2 - The Patients

2009-08-06T04:35:00.001-05:00

First let me begin by admitting that I don't have an MBA or even a degree in economics. I haven't hashed out any numbers to see if this plan would even get off the ground, I have no authority to implement my recommendations, I have no illusions that these suggestions will ever become the blueprint for any sort of significant healthcare reform, and I fully expect to instead be led like the rest of you by the yoke of ~~Hillarycare~~ Obamacare over the cliff of doom as we plummet into a lobotomized pile of decaying socialized medicine zombies.

But it's my blog, and I don't have to support my assertions with facts. These are just the ideas of an anonymous ER doc in the trenches, so take them for what they are worth. I'm not breaking any new ground either, so anyone who thought I was going to reinvent the wheel is going to be just as disappointed as the liberals who won't be happy with any plan that requires any amount of personal responsibility or features any amount of inequity whatsoever.

So what is my solution? I'm not ready to tell you yet. But here's some more table-setting:

For the sake of argument, I'll divide people into 5 categories:

1) Healthy people with a few minor chronic medical problems who can afford insurance and want to be protected against the big expense of a surprise appendectomy or heart attack. We'll call this group "the typical family."

Currently, the typical family is doing OK with our current system, and they ultimately will do well with any system that is put in place. They would like to pay less for medical care, but so would everybody else. They have full access to care right now, but they are afraid that any change in the system will reduce their access to (or quality of) care and/or increase their costs further.

2) Healthy people who work and would like to pay something for their medical care, but lately it seems that medical insurance and healthcare costs too much for them. I'll call this group "the struggling family."

The struggling family is struggling, as usual. They have had a recent ER visit that they are gradually paying off (with difficulty), and they are scared of a really big ticket medical catastrophe that might bankrupt them. They would like to be insured, but would accept access to cheaper care if it were available. I'll also place the healthy young working-class uninsured into this category, but they aren't really scared of a medical catastrophe, they are just betting they will stay healthy and will deal with the consequences (for better or worse) if they fall ill. The medical industry and the responsible insured both need to be protected against the ones who bet wrong, because they drive up costs for everyone else.

3) People who think the government should provide everything for them and don't want to pay anything at all for their care. We'll call this group "the gold tooth trauma victims." They can be sometimes be identified by their gold jewelry, their expensive cell phones, or their dripping bodily fluids. Age 16-30 for the most part, their medical conditions are often self-induced.

The gold tooth club doesn't give a shit about healthcare reform, because they ain't paying nothin' anyway, foo. They give fake addresses, refusing to show ID so that we can't bill them, and they throw away all the prescriptions we write except the vicodin. They'd rather get a shot of antibiotics for their crack-induced bronchitis so they don't have to pay for a prescription.

The medical industry would like to get paid for our often expensive treatment of these patients, however, so we are the ones who need some help from the government in this case. These patients are putting a strain on the system, particularly on the inner-city county hospitals that are the true safety nets of society. They also drive up the cost of everyone else's medical care.

4) Chronically ill people with diseases that require frequent or expensive healthcare visits and are currently uninsurable. I'll call this group "the dialysis patients."

The chronically ill dialysis patients are all covered by Medicare and/or Medicaid, so they actually get outstanding medical care. Others who are chronically ill, for example the multiple sclerosis patients or the rheumatoid arthritis patients who don't quite qualify for disability and can't get medical insurance, are in more of a bind. They can't afford their Tysabri or their Remicade for much longer, and an ER visit or hospital admission is a financial disaster for them. They hope that whatever healthcare reform is passed somehow creates more Rheumatologists and Neurologists and also somehow requires ~~their fellow citizens~~ the government to pay for their expensive medications and therapies that they are increasingly unable to pay for themselves.

5) The poor, the children, and the disabled

Truly poor and disabled patients are already covered by Medicaid, as are poor children, otherwise they may fall into one of the above groups. The sick children of struggling or sick families occasionally fall through the cracks of our current system and deserve a solution.

So what are my solutions? Sorry, I'm going to have to string you along a bit more. These posts require a lot more thought than my typical "Ooh, look at this gross chunk of butt wax" post. I'm almost finished, but I'm still polishing it up a bit. Most of you aren't going to like it anyway, so don't get too excited.

Part 3

Part 3 - Why Incentives are Important

2009-08-06T04:00:00.000-05:00

The goals of my solution to the healthcare crisis are as follows:

1) Restore the free market system to the medical industry
2) Incentives should encourage personal responsibility
3) Increase access to medical care for all groups

Instead of eliminating the concept of multi-tiered medical services, I suggest that we nurture and develop it. The different groups of people I discussed in my last post do not all need the same sort of coverage, and they do not all deserve identical healthcare services just because they happen to have a social security number and a pulse (or not). Some people bring more to the table than others, and I believe that whoever makes the coffee should get to enjoy the first cup. In order for our society to excel we must encourage success, discourage abuse, and protect the helpless.

Achievement of success requires proper encouragement. While some people have a natural drive to excel, most of us will be as lazy and useless as we can possibly get away with. This is why the welfare system is a failure and why all Socialist programs are doomed to mediocrity: if excellence goes unrewarded, then excellence ceases to exist. This can be considered a corollary to the concept of entropy.

The Problem with Medicare/Medicaid

Our present socialized medicine experiment, otherwise known as the CMS, is a perfect example of what happens when incentives are poorly conceived. Currently, payments to physicians for their services are standardized across the nation without regards to outcomes, quality of care, or years of experience. These payments seemingly decrease every year and are burdened with stifling bureaucratic regulations which complicate and restrict the provision of medical care.

When patients are not personally responsible for payment of services, they have no incentive to question or limit the medical services that they seek or that are recommended. The stroked-out granny might as well have that feeding tube placed so that she can be tuned up a little bit in between ICU visits. When they don't have to pay anything for their ICU admission, patients have no financial incentive to go to their dialysis appointment instead of the crack house. When patients pay nothing for their medications, there is no incentive to choose cheaper ones.

Furthermore, the incentive for physicians (since their payments are fixed) is to spend less time with these patients and to perform better-reimbursed (even if questionably necessary) procedures. How can costs not continue to escalate in such a system? The incentives are all wrong!

My proposed solution for this problem is to restore the free market to medicine by allowing balance-billing of Medicare services and copays for Medicaid patients. Only when physicians are allowed to charge market price for their services will the proper incentives be restored. Not only will more physicians be likely to accept Medicare patients, but they will be able to spend more time with them as well. When Medicare patients are given the choice of paying $50 extra to see a physician this week or waiting 4-6 weeks until the "free" doc has an opening, then they are empowered. When families are faced with the prospect of actually paying for some of granny's end-of-life care, then they will likely make more reasonable decisions. And that's money in the budget that can be used for more appropriate indications.

Access of the Medicare population to medical services is already becoming difficult for some, but a true crisis looms in the next couple of decades as the baby-boomers reach retirement age. Those patients who are able to spend some of their extra money to obtain premium medical services should be allowed to do so. Those who cannot may have to rely on the safety net I will propose in my next post.

As far as Medicaid goes, I would institute other reforms in addition to requiring copays for medical care and medications. Although I think it would be difficult to implement, I think mothers on Medicaid should be required to take mandatory depoprovera shots as long as they are receiving public assistance. If they can't support their current family then they shouldn't keep popping out more of them.

Medical insurance

HSAs are the best option for most people, particularly if they are begun early. These plans cost much less than traditional medical insurance, although they feature much higher deductibles and limited prescription benefits. The monthly savings from such a plan can be invested on a pretax basis, and these savings are used to pay for most routine medical needs. These plans encourage both personal and fiscal responsibility, because they essentially reward healthy lifestyles and punish overuse of medical services. These are the proper sorts of incentives we need in this country if we are going to reduce our overall healthcare expenditures. Contrast these incentives with those of the typical Medicaid patient, who gets a bigger monthly check for every extra kid she pumps out that she cannot afford, who gets three free prescriptions per month, and who pays nothing whatsoever to visit the ER as often as she wishes, signing in all of her kids whether they are symptomatic or not. Do you think that would happen if she were responsible for paying the bills? Hell no, it wouldn't.

Once the savings account is well-funded, the financial stress of paying a high deductible for an unexpected medical disaster is eliminated. And of course the expenses in excess of the deductible are covered, preventing financial ruin. Furthermore, the higher cost of medications forces the insured (or their physician) to carefully examine the med list and choose specific medications which balance affordability and efficacy, rather than passing the cost of the latest and greatest medication onto their fellow citizens as in traditional or "single payer" plans.

Of course HSAs do not fit the needs of many chronically ill patients, but in reality such patients are not good candidates for any insurance plan if cost-containment is the goal. And make no mistake, cost-containment is always a goal of anyone who oversees a budget. The unspoken purpose of healthcare rationing is to delay the diagnosis and treatment of the sick in the hope that some of them will tire of jumping through hoops and either get better on their own, give up, or die before they run up the bill. While a healthy patient infuses money into the system, a chronically ill patient who requires expensive tests or therapies is bleeding dollars, no matter whether the coverage is single-payer or private insurance. To the bureaucrats, a cancer patient who dies before starting expensive chemotherapy and bone marrow transplantation only means more money for next year's budget (or their yearly bonus). Therefore if anyone but yourself is paying the bills, you should be aware that they will NEVER have your best interests in mind.

That's why I think that most people should pay for their own medical care whenever possible, depending on outside coverage only as a last resort. Whew, I've still got a lot more to say, but that's enough for now. In the next post, I'll discuss the safety nets I have in mind as well as some ideas that might improve the access of care for many.

Part 4 - The Safety Net

Part 4 - The Safety Net

2009-08-06T03:32:00.001-05:00

(This is the final part of the series. I'll return to lighter topics soon enough.)

So what do we do about the struggling families who can't afford insurance, who don't want to pay for insurance, or who have chronic illnesses that effectively disqualify them from insurance plans? We definitely need a safety net for these folks. If we as a society are willing to pay for the care of the totally disabled, then we should be willing to support the working class when they need a little bit of help too. But as the brilliant Bill Whittle once wrote,

"I’m all for a safety net. It’s the safety hammock I have a problem with."

I think it's important to try to keep health insurance affordable via sensible but not overbearing insurance reforms, so that the healthier segment of the "struggling family" group can purchase private insurance if they choose to pay for a higher tier of healthcare. The sicker or lower-income members of this group should probably be covered by state or federal assistance programs instead. These folks don't need "insurance" anyway...they need someone else to pay their medical bills for them. They are the ones who need government handouts, not the rest of us, so I am against any plan that would force healthcare rationing on the population at large. And to answer a previous question by Ms. Alison Cummins, this same safety net (and the lower tier of care it represents) applies to the previously healthy/insured patient who because of financial or medical disaster finds himself unable to afford the higher tier of medical care he previously enjoyed.

Providing the care

Why not increase indigent medical access by increasing the role (and perhaps the number) of our outstanding medical training programs? We can expand the services provided by medical students and residents at the state and county level, using a sliding scale for charges based upon income. In my experience, indigent patients are typically appreciative of the relatively inexpensive and compassionate care provided by medical trainees. Insured patients, on the other hand, occasionally disdain such treatment. Despite the perception of a lower tier, the quality of care that is provided by housestaff and supervised by teaching physicians is often superior to that offered in private facilities. It surely isn't as convenient, but convenience is something you pay extra for.

I suggest that community indigent clinics could also be staffed on a rotating basis by physicians who have been disciplined by their state medical boards as a retribution for various medical misbehaviors. Volunteer physicians might also staff such clinics if they were offered some sort of tax writeoff and malpractice protection.

The additional cost to patients

Access to discounted rates for medical services do not come without a cost to the relatively indigent but able-bodied individuals. They should have to make some sacrifices in order to obtain their bargain medical care. They will have to pay their dues by allowing themselves to be on the teaching service, to obtain primary care by less-experienced (but supervised) physicians, and to accept the ~~possibility~~ likelihood of increased waiting times, fewer clinic locations, and decreased availability of expensive therapies. They may be able to obtain certain more expensive services or medications by participating in research studies coordinated by the teaching hospitals.

Funding for these programs should be primarily the responsibility of the individual states

I suggest that each state should be primarily responsible for funding their own indigent and preventive medicine programs as they see fit, perhaps with some limited federal assistance or incentives. In Texas we fund our programs with sales taxes and property taxes, and we still don't have a state income tax. Teaching hospitals should establish or expand programs which send medical students and residents to satellite facilities in their state for clinical rotations. That would provide better access of care to uninsured patients, enhance the educational experience of budding physicians, and perhaps increase student interest in primary care. Expanding the concept of student loan deferment for physicians who agree to practice in these rural communities for a given period of time might be a good idea too.

EMTALA - follow the original intent

Acceptance of transfers of stabilized indigent patients who present to community hospitals should be expedited by state/county facilities so that definitive care can be provided by the funded teaching hospitals. If EMTALA is going to remain the law of the land, then the original concept should be followed rather than the tar baby into which it has evolved.

Tort reform can increase access and reduce costs
(edited for clarity)

One of the biggest crises in America today is the increasing difficulty of obtaining emergency surgical specialty care. Neurosurgeons, Orthopedists, Ophthalmologists, and Plastic Surgeons, for example, are avoiding ER call by giving up their hospital privileges to practice in free-standing surgical centers, leaving trauma patients in some areas with limited access to critically important services.

Optimally, the provision of free medical care (edit: such as that provided under EMTALA) should operate under the protection of Good Samaritan laws, thereby eliminating the prospect of malpractice torts and the extra associated costs of defensive medicine. If a patient is receiving free medical care, why in the heck should he be allowed to sue for a bad outcome? I think more (specialist) physicians would be willing to provide unreimbursed (emergency) treatment if they were immune from lawsuits. Alternatively, incentives to provide uncompensated medical care could be given to physicians by allowing them to write off the costs of their unpaid services as charitable donations.

"Self pay" patients should also be able to barter for discounted emergency or nonemergency care if they agree to sign a waiver releasing the treating physician from malpractice liability, or perhaps limiting the scope of such liability. With the current system, the patient is forced to pay for maximum liability protection for each and every encounter. High risk patients, therefore, often find it difficult to obtain medical treatment. Allowing more flexibility in this area is another potential way to reduce cost and increase access to medical services.

The trauma fund

Finally, a catastrophic medical fund should be established to help pay for uncompensated trauma care. And I would suggest that this money should be distributed by each state wherever it is needed most, such as a rural EMS system, an inner city trauma center, a LifeFlight program, or even to build additional county medical facilities. This could be partially funded by additional levies on automobile sales, drivers licensing, automobile registration, gasoline, traffic violations or various misdemeanors and felonies. Other options include specific taxes on the sales of motorcycles, skateboards, or rock-climbing equipment to name a few only partially tongue-in-cheek suggestions. The most outstanding trauma surgery residents I've had the pleasure to work with all went on to make a living doing more lucrative lower-risk elective surgeries such as bariatric procedures and laparoscopic fundoplications. If we don't provide incentives to do the dirty work, not enough capable specialists are going to be around to do it.

Conclusion

I believe that my plan would make healthcare more accessible to Medicare patients while increasing the efficiency of the Medicare and Medicaid programs. It might decrease the cost of insurance to make it more accessible to the middle class while still maintaining the benefits of the current system for the insured. And I suggest that it would provide increased access to care of the uninsured. What more could you want from a healthcare plan?

Now I can badmouth ~~Hillarycare~~ Obamacare to my hearts content without anyone asking me snidely, "well what's your plan then?"
Here it is...take it or leave it.

"I'm Not a Doctor...."

2009-08-03T12:32:00.003-05:00

Why I Read Charts (of my admitted patients)

2009-07-12T11:12:00.006-05:00

I recently treated two patients, one with chest pain and one without.

The one without chest pain was much sicker with some dangerous arrhythmias, and while his initial cardiac enzymes in the ER were negative, the following morning his troponin was over 50. Yet he survives, so far, despite his advanced age.

The one with chest pain didn't seem particularly sick at all, and his Cardiologist was unimpressed with my presentation. Stable ECG, negative cardiac enzymes, and atypical features in an anxious patient with a previously negative workup suggests maybe he could go home, said he. Fortunately the Hospitalist agreed to admit him after some negotiation. This patient expired the next day.

Reading the electronic medical record of my admitted patients gives me perspective and feedback that is difficult to acquire in any other way. Apparently some HR departments frown on such intrusions into patient privacy, one more way that bureaucrats with good intentions sabotage the practice of medicine.

In my experience, patients are grateful that I care enough about them to learn how things went after our brief interaction in the ER.

Why Freestanding ERs love EMTALA

2009-06-26T09:02:00.005-05:00

As we have previously discussed, EMTALA applies only to "participating hospitals" -- i.e., to hospitals which have entered into "provider agreements" under which they will accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program for services provided to beneficiaries of that program.

Most freestanding ERs do not participate in the Medicare program, so we are not bound by the onerous restrictions of EMTALA. Hospitals, on the other hand, are not so fortunate.

A seldom-mentioned clause of the EMTALA law states that:

A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. 42 CFR 489.24(f)]

The receiving hospital will be obligated to accept the transfer in most cases, so long as it has the ability to treat the patient and its capabilities exceed those of the referring hospital.

Every hospital's capabilities exceed those of the typical freestanding ER (at least with regards to the presence of inpatient beds), so they cannot refuse to accept a transfer from us unless they want to risk a $50,000 EMTALA violation and revocation of their Medicare provider agreement (the "death penalty").

So even if we are required to provide medical screening examinations and (perhaps) stabilization of uninsured patients with emergencies, we can still transfer these money-losers to the hospital of our choice with the federal government backing us up.

That's a nice hospital you've got there. It'd be a shame if anything happened to it.

I believe the clause requiring Texas freestanding ERs to provide medical screening examinations is not only poorly written but unconstitutional, so I expect it to be expunged. I'll explain why in my next post.

The Texas Freestanding ER Act

2009-06-24T01:36:00.006-05:00

Last week Governor Rick Perry signed C.S.H.B. (Committee Substitute House Bill) No. 1357 which regulates and defines freestanding emergency facilities.

A "freestanding emergency medical care facility" means a facility, structurally separate and distinct from a hospital and not affiliated with a hospital licensed under Chapter 241, that receives an individual and provides medical treatment or stabilization to the individual in an emergency or for a condition that requires immediate medical care.

C.S.H.B. 1357 establishes procedures for license application, issuance, denial, suspension, probation, and revocation. The bill provides for the emergency suspension of a license and injunction for a violation of licensing requirements. The bill provides for facility inspection, fees, and the freestanding emergency medical care facility licensing fund.

The bill prohibits the minimum operating hours of such a licensed facility from being less than 7 days each week and 12 hours each day. There will be separate licensing for 12 hour and 24 hour facilities, perhaps opening the door to insurers to pay the 12 hour facilities less. Facilities open less than 24 hours per day will not be able to use the word "emergency" in their advertising, but that restriction will not be enforced for 2 years.

C.S.H.B. 1357 requires a facility "to provide to each facility patient, without regard to the individual's ability to pay, an appropriate medical screening examination within the facility's capability, including ancillary services routinely available to the facility, to determine whether an emergency medical condition exists." The bill does not specify that these patients must be stabilized as with the EMTALA law, and since these facilities are not required to follow EMTALA anyway, perhaps a medical screening exam followed by a 911 call would suffice for uninsured patients. That remains to be seen.

Perhaps the most important section deals with insurance reimbursement. The bill requires insurers to provide coverage and reimbursement for services originating in a freestanding emergency medical care facility. Formerly, some insurers would refuse to pay the facility fee for emergency care not obtained in a "hospital's" emergency department. Not anymore.

C.S.H.B. 1357 requires a freestanding emergency medical care facility to obtain a license not later than September 1, 2010.

Drive Through Vicodin Clinic

2009-06-16T21:48:00.006-05:00

My new ER has a little window on the side like the drive through at a McDonald's, and I was joking with my friend today that I could use it as a drive through vicodin clinic. Then I saw that Dr. Whitecoat linked to this article about a Stanford University experiment which pilots the concept of drive through triage.

That caused me to erect a capitalist tent of sorts, as I pondered that one could easily make a fortune with such an enterprise. I can already bill a 99283 ER visit and a level 1 facility fee without ever touching the smelly patients, now they don't even have to come in the door!

Procedure Code: CPT 99283 – Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history, an expanded problem focused examination, and medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate severity.

According to ACEP guidelines, any medical condition requiring prescription drug management supports a 99283 charge. So by definition, if I determine that your headache requires a prescription for a couple dozen vicodin and your credit card has enough remaining balance to cover my charges, then it was nice doing business with you. Have a nice day. But how much do I need to document to support the charge?

Honestly, if you're paying cash or credit, it doesn't really matter. I don't take Medicare, so the CMS isn't going to review your chart. But just to be thorough, I can document a level 3 history and physical without you having to unbuckle your seatbelt. Here's how:

Just give your order, I mean your history, to the nurse via our conveniently covered and HIPAA-compliant ordering kiosk behind the building. There will be helpful menus to guide you through your chief complaint and HPI. Just pick one answer from each box to describe your pain (location, description, duration, severity, exacerbating factors, relieving factors). When you pull up to the window, the nurse will visually inspect you for signs of distress and place a small device on your finger to measure your pulse and blood pressure while your credit card is swiped.

I'll be at the next window, where I will visually inspect you for alertness and lack of distress, a normocephalic and atraumatic head examination, eyes without redness or discharge, normal respiratory effort and lack of retractions, a quick evaluation of your affect and mood, and the briefest of cranial nerve examinations and speech evaluation.

That's all there is to it! In five minutes, you're on your way to the pharmacy with your prescription in hand, and I'm three hundred dollars richer. We both win.

Coming soon to a neighborhood near you.

Make an Appointment in the ER

2009-06-04T17:37:00.004-05:00

Here is an e-mail I received from Tyler Kiley, the founder of InQuickER. I am always amazed to see that people really do read our blogs! I have no financial interest in this company, and as usual I am never paid for any content I place on my blog. I post this because I am impressed with their innovative concept and because it refutes some of the false assumptions made on other blogs about this type of service. Adapt or fail, folks.

Hello!

My name is Tyler Kiley, and I'm the CEO and founder of InQuickER. We've maintained a low profile and quiet existence for the past two years, but I see our company has become the talk of the medical town in the past few days. Wow!

There is quite a bit of discussion on some of the nursing blogs about the risk that a service like InQuickER will increase use of the ED for inappropriate conditions. Two years ago when we started this service, I was very concerned about that issue; however, it appears this is not a problem right now. In our follow-up interviews and research with patients, we are finding that InQuickER is not causing patients to go to the ED when they would have otherwise gone to a PCP or an urgent care. We aren't causing patients to use the ER as a source of primary care; rather, much of our current volume comes from patients who would have ordinarily gone to another ED that doesn't offer the InQuickER service. Patients who have decided to go to the ER are willing to drive long distances to use our partner ERs because they would much rather drive 30 minutes than sit in the waiting room for two hours!

We do offer treatment appointments up to 12 hours in advance, but we've found that patients simply don't use this feature; over 96% of our treatment appointments are set less than four hours in advance. I think this is a relatively strong metric indicating that our service is being used by patients who do, indeed, need timely treatment.

I'm surprised that there is so much antagonism toward this service in the last few days; at our pilot hospitals, we have received a very positive response from the nursing staff. For the most part, InQuickER patients are more satisfied, more compliant, less stressed, and better prepared than other ER patients; I think this is partly because they haven't had the negative experience of sitting in the waiting room for hours, wondering when they will be seen by the doctor.

Ultimately, we give the nursing staff more flexibility in the waiting room; nurses have the opportunity to call patients in earlier than their automatically-generated appointment time if warranted, but InQuickER means that the nurses have more information, more control of the flow of incoming patients, and fewer people in the waiting room. Eventually, we would like to work with urgent care centers and open access PCPs as well, but we simply haven't had the right resources and partners to offer those services yet.

Thanks for taking an interest in our service!

Tyler Kiley
Founder and CEO
InQuickER, LLC

What is an ER For?

2009-06-03T21:44:00.006-05:00

Evaluating patients for the presence of emergency conditions.

Stabilizing and treating patients if necessary, and making an appropriate disposition.

Reassuring patients if they do not have an emergency medical condition.

Educating them about warning signs that might indicate their condition is becoming an emergency.

~~Arrogantly dismissing their complaints as trivial wastes of our time~~.

Video Game Poisoning

2009-05-27T18:08:00.006-05:00

If you use a generator to power your X-box after a hurricane, you might get sick. And you might cause Al Gore to have angina.

So use a long extension cord.

Money quote: “We usually have patients arriving in the emergency department with carbon monoxide poisoning because they tried to keep food fresh, run a fan or home air conditioner, but not power electronic gadgets,” Dr. Caroline Fife, a UT associate professor of medicine, said in a news release.

Memorial Day

2009-05-25T10:53:00.004-05:00

Thanks to those who gave all to protect our freedoms.

More from Cox and Forkum

Tool Time

2009-05-20T09:31:00.003-05:00

A doctor in rural Australia used a handyman's power drill to bore a hole into the skull of a boy with a severe head injury, saving his life.

Nicholas Rossi fell off his bike on Friday in the small Victoria state city of Maryborough, hitting his head on the pavement, his father, Michael, said Wednesday. By the time Rossi got to the hospital, he was slipping in and out of consciousness.

The doctor on duty, Rob Carson, quickly recognized the boy was experiencing potentially fatal bleeding on the brain and knew he had only minutes to make a hole in the boy's skull to relieve the pressure.

But the small hospital was not equipped with neurological drills — so Carson sent for a household drill from the maintenance room.

Carson called a neurosurgeon in the state capital of Melbourne for help, who talked Carson through the procedure — which he had never before attempted — by telling him where to aim the drill and how deep to go.

What is an ER?

2009-05-19T14:42:00.023-05:00

ERP and I had a discussion yesterday that raised some interesting questions which I believe warrant further consideration. His post was about the frustration with the unpaid mandate of EMTALA and the related lawsuit by some California physicians seeking increased reimbursement for their treatment of Medicaid patients.

He complained that since ER docs are legally required to see these patients, it isn't fair that we aren't reimbursed adequately for our services. I reminded him that a new model of emergency medicine is emerging, the freestanding ERs, some of which do not accept Medicare or Medicaid and therefore are not legally required to follow EMTALA. His position is that such facilities are not really ERs at all, that it is our duty as emergency physicians to see every patient that presents for care whether they have the inclination or ability to pay us or not, and if we do not treat all comers then we are not practicing Emergency Medicine.

Perhaps he is right, but one could make the same moral argument for all physicians regardless of specialty. Shouldn't all physicians have the quality of beneficence? Yet only emergency physicians and those specialists taking ER call for a Medicare-participating facility are legally required to provide unreimbursed care. When we try to define the essence of the practice of Emergency Medicine, are we talking about the legal requirement or a moral requirement?

The legal requirement is undefined. A facility may provide emergency medical services without being open 24 hours a day or 7 days a week. There is no legal requirement that an ER must be physically attached to a hospital, affiliated with a hospital, certified by JCAHO, or even staffed by trained or experienced emergency physicians. Board certification is certainly not required, whether in EM or by any other specialty. And, perhaps most importantly, there is no legal requirement (yet) that any ER, physician, or medical facility accept Medicare or Medicaid.

Some rural ERs are reportedly staffed by a single unsupervised physician assistant, according to one of my commenters. Others are not supported by adequate hospital facilities to manage complex injuries or illnesses, so the sickest or most injured patients must be transferred elsewhere. Most hospital-based ERs without comprehensive specialty backup must at least occasionally transfer neurosurgical injuries, ophthalmic injuries, penetrating trauma, pediatric cases, or a variety of other conditions based upon the expertise of their medical staff or the whims of their call schedule. Others must transfer patients when there are no available inpatient beds. Is such a facility more of a "real ER" than a for-profit freestanding ER with similar staff, more sophisticated equipment, and superior specialty backup? Of course not.

What of the case of the University of Chicago ER, who technically followed EMTALA when they medically screened, stabilized, and discharged the boy whose lip was bitten off by a pit bull? They certainly met the legal definition of an ER that night. In some cases, EMTALA causes us to provide worse care than if that law didn't exist. When an ER whose hospital has no trauma surgeon on staff receives a walk-in patient with a gun shot wound, they often waste precious time "stabilizing" the patient and trying to find an appropriate accepting hospital when the patient might be better served by simply calling 911 from the lobby and sending him immediately to the nearest trauma center. When a patient who has been sexually assaulted presents to an emergency facility without the properly trained staff to collect forensic evidence, she doesn't need to wait 2 hours for a receiving hospital to send the transfer paperwork, she needs to be directed to the proper facility without causing her any more discomfort and delay than necessary.

Following natural disasters, I've worked in emergency departments (yes, pleural) without power, using a headlight to find my way down the hallway. We had no X-ray or laboratory facilities whatsoever, so for those weekends we were essentially practicing 19th century emergency medicine. And yet we were still an ER, both by my definition and ERP's, because we turned no patient away. All you really need in an ER is a good doctor, a good nurse, some basic equipment, and good sense. Increased assets make some ERs more capable than others, but the underlying job is still the same: diagnose, stabilize, and make a proper disposition.

I don't think that emergency physicians should be held to a higher moral standard than physicians of any other specialty, and I believe that all physicians who choose not to work for the government should have the right to refuse to treat any patient. Of course we can and will continue to provide charity care, but we will do so because we are compassionate physicians, not because the practice of Emergency Medicine specifically requires it of us. By refusing government subsidies and freeing ourselves from the requirements of EMTALA, we will be empowered to control the frequency and volume of our charity like other citizens.

Quote of the Year (So Far)

2009-05-19T13:37:00.000-05:00

"Status post bitch-stompin'"

Comedy of Errors

2009-05-16T07:15:00.004-05:00

Administrators require emergency nurses to document a lot of crap that has nothing to do with the patient's actual emergency condition. We have domestic violence screening questions, tuberculosis screening questions, immunization status queries, and so on and so on. These add a significant amount of time and effort to the triage process. Fortunately, we now use electronic medical records which have little checkboxes for those questions in order to speed up the process.

I'm not certain, but I suspect these boxes must be checked or else the triage note cannot be completed. The combination of these two faulty systems sometimes results in unintentional comedy:

1) 6 month old with fever and cough. Denies suicidal ideation. (He is crying a lot though. Maybe he's depressed)

2) 55 year old with CPR in progress. Denies flu-like symptoms. (Stop compressions! Have you been coughing? Any fever? Hello!?!)

3) 35 year old assaulted by spouse, facial contusions, lip laceration. Admits to being threatened by others. (Bet the nurse felt silly asking that one)

A Lesson for the LA Lakers

2009-05-12T09:11:00.003-05:00

I see you've been struggling at the free throw line lately, and I thought you could use a little help from Coach Kige. Please watch this video carefully, and good luck tonight.

And for our National League opponents, here's a baseball lesson from the coach.

via the Z Report

Happy Mother's Day

2009-05-10T13:05:00.003-05:00

Mom, when I think of you, I think of your wisdom, kindness, temperance, and patience and wish I had more of those qualities. Although we don't see each other much anymore, I think of you often. As I get older and try to raise my own children as you raised me, I appreciate you more every year. And as your grandchildren enter their teenage years, I pray that they don't give me as much grief as I gave you, but if they do, I pray that I am able to be as strong and supportive as you were (and still are). Thank you for always being there for me.

Love,

Your son

And Happy Mother's Day to all the other mothers reading this too.

How Would You Respond?

2009-05-08T19:13:00.008-05:00

You are suturing the wound of an elderly demented woman who, while discussing the long wait to be seen, correctly states that "There sure were a lot of blacks in the waiting room." Her family is horrified and embarrassed.

You:

1) Inform the patient that it's not politically correct to make any comments whatsoever about people of another race, even if accurate.

2) Cite the study you read in the Annals about the relative overutilization of Emergency Departments by African-Americans.

3) Reply "Yes, we're pretty busy tonight" as you sew faster.

4) Say "Wow, the Aricept must be working!"

5) Tell an off-color joke.

6) _________________

Quote of the Day

2009-05-06T03:28:00.008-05:00

"I too eat flour. I find that Martha White self-rising flour is the best. I just can't stay away from it. I just love the stuff!

If flour was crack I would be hurtin' bad!! I am glad to read that I am NOT alone. I felt like I was carrying around a dirty little secret.

So all of you flour-eating people, lets raise our flour filled bowls and spoons and eat like we just don't care!!! Party over here!!!"

Starting the Hypothermia Protocol

2009-04-07T12:32:00.008-05:00

I'm not calling the code, so don't even ask about harvesting bits and pieces. There might be some life left in this blog yet, but it's been having some serious rhythm disturbances recently, and now it's been flatline for a month. That last post was just an agonal beat after Nurse K activated the shock collar. I'm just going to pack it in ice for now and see what happens.

The good news is, I've been working on starting my own business. The bad news is, it takes up a lot of my free time (and money), so this blog is officially on hiatus for the time being. Thanks for visiting, and don't hold your breath, but I might see you later.

The John Galt Memorial Freestanding Emergency Center

2009-03-28T16:59:00.005-05:00

Coming soon, to a neighborhood near you.

Looters and moochers not welcome.

On Vacation

2009-03-12T19:19:00.003-05:00

Aloha.

Misunderstanding

2009-03-04T02:17:00.001-06:00

A nurse walks into the room and greets her patient, who is busy typing on his laptop in no apparent distress. He looks up at her briefly but says nothing and continues his work.

"So tell me what brings you in to see us," says the nurse, a bit perturbed by his rudeness. He completely ignores her and continues to type without saying a word.

She leaves the room in a huff and tells her colleagues about the jerk in room 2, only to learn that he is a deaf-mute patient who communicates by typing. When she returned, she found he had finished typing his chief complaint and a brief history.

Self-censoring the Medical Record

2009-03-02T05:23:00.004-06:00

A patient presented to the ER with a benign complaint at 3 am. She was incidentally noted to have moderately elevated blood pressure, and she appeared much more awake and talkative than the usual 3 am patient. She admitted to recent cocaine use but requested that I not mention that fact in the medical record for fear of possible repercussions. She was a HENRY with good insurance and didn't want to jeopardize those things if her secret were somehow discovered.

Since the blood pressure wasn't dangerously high and the drug use was not even tangentially related to her initial presenting complaint, I complied with her request, documenting only that we discussed lifestyle modifications and secondary causes of hypertension, etc.

When electronic medical records become more common and more widely (if not universally) accessible, I suspect there are going to be an increasing number of patients who will be hesitant to tell us embarrassing and potentially career-threatening information about themselves. Perhaps big brother shouldn't have any more information about us than necessary.

With the possibility of a nationalized healthcare system and the subsequent rationing of care and passive culling of the herd that looms on the horizon, even a one-time chart notation of serious drug use might make receiving certain services more difficult when viewed through the eyes of a cold-blooded single-payer bureaucrat charged with distributing scarce resources. If one happens to need a kidney transplant in a decade or so, it might be better to have a clean record.

But when patients don't give us the whole story, it can make our job very difficult.

Night Nurse

2009-03-02T04:19:00.004-06:00

Tell her try your best just to make it quick
Whom attend to the sick
'Cause there must be something she can do
This heart is broken in two
Tell her it's a case of emergency
There's a patient by the name of Gregory

Night nurse
Only you alone can quench this Jah thirst
My night nurse, oh gosh
Oh the pain it's getting worse
I don't wanna see no doc
I need attendance from my nurse around the clock

'Cause there's no prescription for me
She's the one, the only remedy

Doomed to Failure

2009-02-26T00:26:00.012-06:00

My initial impression of President Obama's healthcare plan is one of suspicion laced with grave concern and sprinkled with disdain. Surely he must realize that expanding Medicaid is not providing universal healthcare - Medicaid patients are turned away from many (most?) outpatient facilities already because the reimbursement rates are so low that each patient is a money-loser for the practice. I'm suspicious that he's using this plan as a token gesture to claim that he's fixed the uninsured problem. Guaranteeing coverage does not guarantee access, particularly when that coverage is pathetically insufficient. Even raising reimbursement to Medicare levels would still leave many patients without access to healthcare.

Another of his proposals is to eliminate Medicare payments for patients who are re-admitted to a hospital within 30 days of their last discharge. Like many liberal ideas, this sounds good in theory; if patients were appropriately treated the first time, then they should not require readmission for at least another month, right?. Improving the quality of care is a worthy goal, but when one's initial assumption is wrong then the conclusions will be wrong too.

A noncompliant dialysis patient, for example, may miss a couple of his outpatient treatments and present to the ER with life-threatening hyperkalemia (elevated potassium) or pulmonary edema (fluid in the lungs). Some of these patients don't go to their dialysis centers at all, they just come to the ER when they can't breathe. Instead of admitting these repeat offenders to the ICU, our incentive will be to dialyze them emergently in the ER and discharge them after several hours of critical care. That's good for ER docs (cha-ching!) since we can run up huge critical care bills on Medicare's tab, but not so good for the long line of patients in the waiting room who have discovered that they can't get an appointment with a doctor because nobody takes their newly-provided Medicaid.

Medicare patients, by definition, are either old, sick, or both, so they are more likely to require frequent admissions. When grandma has a TIA ("mini-stroke") 27 days after her last admission for pneumonia, the hospital's (and any on call physician's) incentive is going to be to discharge her from the ER rather than admit her to the hospital for an uncompensated megaworkup. So the ER docs stuck in the middle will do an 8-12 hour TIA workup with Neurology consultation in the ER, further backing up the waiting room. I could go on and on, but these examples should suffice. Patient care will suffer under this plan, and costs will not be reduced.

Other Obama initiatives like "Expanding the Hospital Quality Improvement Program" and "Improving Medicare and Medicaid payment accuracy" are just JCAHO-like regulatory mandates and excuses for payment denials which will not increase access to care in any way whatsoever, but will definitely make it harder for hospitals to stay in business. This plan is simply bureaucracy at its worst. My plan is better.

UPDATE: More concerns from Buckeye Surgeon and Dr. Whitecoat, great reads both. And 911doc reminds us that socialists were trying the same crap decades ago.

On Needing Eyeglasses

2009-02-25T17:53:00.001-06:00

I've noticed some decline in my visual acuity for quite some time now, but as with most inconveniences, one makes allowances and carries on. Thanks to some poor planning with my FLEX account, I discovered that I needed to spend a big pile of cash on either my teeth or my eyes within the next month or else donate the funds to people who I've never met and whose very existence I hypothetically despise. Since I've already spent a bundle to fix my teeth in the past couple of years, the eye exam was a logical choice.

I was secretly hoping that my vision wasn't so bad after all, but I was only fooling myself. I could barely read the 20/30 line, and the benefits of correction were immediately obvious. So it seems that the second half of my life will be spent looking through corrective lenses. Maybe they'll make me look more distinguished or at least hide the bags under my eyes.

Coming soon: "On needing a cane"

A Pitibull Situation in Chicago

2009-02-24T09:36:00.011-06:00

Shadowfax has been following the case of the child in Chicago who was attacked by a Pit Bull and discharged from the ER without his apparently severe facial lacerations being closed. This post started as a reply but got too long, so here it is.

Delayed wound closure, even of a dog bite to the face, is not necessarily unethical and in some cases (heavy contamination, lack of specialist availability, delayed presentation) is itself the standard of care. Referral of uninsured or Medicaid patients to county facilities is not unethical either, and in many situations is the only reasonable option available. More and more physicians are refusing Medicare, Medicaid, and the uninsured, so there is no guarantee these patients will be seen when they follow up as an outpatient unless they go to a county facility.

It's the combination of these two issues that is controversial. Activists are using the drama of an "untreated" disfiguring attack (on a child!) to advance their socialized medicine agenda, much like their ideologues use the "unfairness" of foreclosure to advance their Socialist goals.

While it's tempting to blame Michelle Obama and the hospital policies she reportedly helped design, this particular disposition was made in the trenches by an ER doc, not in the upstairs offices by a committee. Not having seen the wounds, it's hard to comment on the propriety of the decision, but I will say that it's becoming increasingly difficult to have Plastic Surgeons come to the ER to repair wounds, much less to have them admit these patients. The days of "if a patient requests Plastics, then they get Plastics" are becoming but a fond memory.

I've personally had to suture several uncomfortably complex wounds I would have much rather had a specialist fix because the specialist just wasn't going to come in. "Just do the best you can to get it together, and I'll see them in my office," they say. We wield the "last resort" of requiring their presence via EMTALA with caution, because if we use that weapon injudiciously we might find ourselves out of a job. So we do the best we can and move on to the next patient.

There are few wounds that *have* to be fixed right away and even some gaping disfiguring wounds with flaps hanging about can technically be approximated, bandaged, and cosmetically fixed later. Is this the type of care that I'd want for my own son? No, but I pay for my own son's medical care. This controversy isn't about wound care though, it's about indigent care. Everything is politics.

The Obesity Epidemic

2009-02-23T10:42:00.004-06:00

Are there contributing factors other than overeating and lack of exercise? Some interesting theories here, including viruses, microwave ovens, air conditioning, and artificial sweeteners.

via Conservative Grapevine

Duck Hunt Made Easy

2009-02-23T09:23:00.002-06:00

From the comments: "The weapon of choice for the zombie apocalypse."

Get Rid of Your Medical Insurance

2009-02-20T14:57:00.009-06:00

It makes good economic sense for many people to dump their medical insurance. For those who rent apartments and ride the bus, it doesn't matter if their credit rating gets destroyed by a collection agency or three, so there is no reason they need to pay for their EMTALA-mandated emergency medical visits. They should save that money to buy their prescriptions (and staples like food, cigarettes, and booze).

Those middle class folks stuck in homes they can't sell in the depressed housing market and resigned to driving beat-up old cars during the Obama recession aren't looking at taking out a loan in the near future anyway, so they shouldn't worry about their credit rating either. They should use the money they save by dropping medical insurance to help make their next mortgage or car payment. Heck, they might have enough left over for a big screen TV, or at least an iPhone.

Worried about paying for college? The "rich" don't qualify for school loans anyway, and the poor have guaranteed loans and grants from the government. No need to worry about bad credit when the worse off you are, the better your chances for help. Living in a nanny state has its benefits....enjoy them.

Screw the insurance companies, the hospitals, and the doctors. Demand your right to free healthcare. You've got more important things to spend your hard-earned money on.

Symbolism and Irony

2009-02-16T16:05:00.006-06:00

Obama coins are like his presidency - not the change many had hoped for.

via Gateway Pundit

I am the Wolf

2009-02-15T15:37:00.007-06:00

I solve problems.

I've had an interesting variety of patients lately. That's the best part about my job - dealing with the unexpected. A sudden life-altering event has occurred, and a frightened family fears the worst. They seem to think their adrenaline should be contagious, that we should all be as frantic and scared as they are. They don't understand that my adrenaline only makes me think faster and more clearly. Outwardly my demeanor never changes, except that I might dispense with some of the usual pleasantries.

If I'm curt with you it's because time is a factor. I think fast, I talk fast and I need you guys to act fast if you wanna get out of this.

But I don't get scared and I'm not going to run around in circles wringing my hands and crying. Just answer my questions quickly, do as I say, and I'll fix your problem for you. That's what I do - I solve problems. With people.

That's thirty minutes away. I'll be there in ten.

Oh yeah, I also drive real f***ing fast, so keep up.

Take the What Pulp Fiction Character Are You? quiz.

Tough Guys

2009-02-13T10:40:00.005-06:00

I can't get it to embed for some reason, so you have to go here.

The Stinger

2009-02-07T12:22:00.001-06:00

Cervical spine injuries cause about 6000 deaths and 5000 new cases of quadriplegia per year. These well-known consequences of a "broken neck" usually mean that patients with these injuries are brought by EMS crews to the ER already taped to a rigid and uncomfortable backboard with a stiff cervical collar preventing any movement of the spinal column until we can "clear" them of a dangerous fracture or subluxation.

Not everyone with a neck injury calls 911, however, and some of them walk in themselves. Such was the case of a high school football player whose coaches thought had suffered a "stinger" during a game. After a tackle, he developed neck pain and numbness to the left arm. He left the game and fortunately didn't return, but his parents were concerned enough to bring him to the ER afterward.

When someone walks into the ER on their own power, our clinical suspicion for serious injury is sometimes reduced. I can only assume this is why he wasn't immobilized in triage. When I entered the room, I found him sitting upright in a wheelchair in mild distress from pain, still wearing his sweaty football uniform but not his helmet. He appeared to be holding his head very still so as not to move his neck at all. He was exquisitely tender to the lower midline of his posterior neck. He was slightly weak in his left upper arm but had normal grip strength.

I immediately placed him in a cervical collar and we carefully laid him down on a backboard. I skipped the X-rays and sent him straight to the CT scanner, where he was found to have a burst fracture of C4 and some injuries to the posterior elements of C5.

In Texas it's hard to tell a teenager and his family that he'll never play football again, but the good news overshadowed the bad: after his surgery he left the hospital 3 days later with no neurological deficit whatsoever, one of the luckiest patients I've ever seen.

Quote of the Day

2009-02-03T14:23:00.005-06:00

Sorry about the dearth of medical posts, I haven't had the BUMA lately. But this quote is simply delicious:

"Here's a question for (Tom) Daschle : When you amended your taxes and coughed up about $140,000 in back taxes plus interest, did you feel like you were stimulating the economy as much as you would have if you had spent that money yourself?"

And for that matter, did you feel more patriotic?

UPDATE: It gets better. A LOT better: "A penny saved is a penny earned! Especially when you save it by not paying your taxes."

via Instapundit

Super Bowl Stadium Snack Tray

2009-01-29T16:02:00.002-06:00

TOTAL CALORIES: 24,375
TOTAL GRAMS OF FAT: 1,285
TOTAL COST: $86.47

Step by step instructions here.

Four Chord Songs

2009-01-27T09:29:00.002-06:00

Pretty cool.

h/t Ace.

The Uselessness of the TIMI Risk Score

2009-01-22T19:47:00.009-06:00

Supposedly one of the measures which is evaluated during the process of "Chest Pain Center Accreditation" is the use of the TIMI Risk Score in the Emergency Department:

Age over 65 years

More than 3 risk factors for CAD

Known CAD (stenosis ≥ 50%)

ASA Use in Past 7 days

Severe angina (≥ 2 episodes within 24 hrs)

ST changes ≥ 0.5mm

Positive Cardiac Marker

Add one point for each factor, total up the points, and you now have an estimate of the likelihood in the next 14 days of all-cause mortality, myocardial infarction, or severe recurrent ischemia requiring urgent revascularization.

In theory this sounds like a neat way to streamline and validate our medical decision-making, but in practice this system is totally worthless to us in the Emergency Department. Consider these examples:

1) The 64 year old with known coronary artery disease status post stenting of his proximal LAD, who has neglected to take his aspirin or plavix for the past week, who presents with a single severe episode of unstable angina that woke him from sleep 2 hours ago, who has significant ST depression, but his first set of cardiac enzymes is negative. He has only a TIMI risk score of 2, so he supposedly has only an 8% risk of death. I guess we should send him home.

2) The 44 year old hypertensive Marlboro man with chest pain and a positive troponin but no ECG changes gets only a TIMI score of 1, so his risk of death is even lower, only 5%. He can follow up next week, I suppose. Be sure to tell him to come back if he gets worse.

In practice, we aren't sending anyone home with ischemic ECG changes or elevated cardiac enzymes, so I find that this scoring system is completely useless to my practice. Protocol-driven medical decision-making is always going to be inferior to expert clinical judgment. This is also one of the reasons you should be suspicious of the current fad of the various "accreditation" merit badges hospitals proudly display. They are equally worthless.

Thank You President Bush

2009-01-21T01:00:00.010-06:00

You can leave a thank you message to President Bush here.

UPDATE: And you can read the letter from the Bush twins to the Obama girls here.

Rationing AICDs in Canada

2009-01-20T03:47:00.004-06:00

Dr. Wes on rationing of electrophysiology services in Canada:

I asked how many defibrillators (they) performed a year and asked who paid for them, and she said the government. "But we got authorization to do five more devices next year," she said.

"Only five?" I asked in disbelief.

"Yep, and we were lucky. Other centers got fewer. They're expensive, you know. We have to be very careful about who we select to get one of those. It's not like America - people here are used to waiting."

And then I wondered: would America ever be capable of overt rationing, as in Canada?

I hope not.

Jack Johnson

2009-01-19T15:37:00.006-06:00

On this day of remembrance for Martin Luther King Jr. and the eve of the historic inauguration of Barack Obama, I suggest to those of you who are unfamiliar with the story of the "Galveston Giant" that his life is worth remembering today as well.

It was just over 100 years ago on December 26, 1908 when Jack Johnson became the first black heavyweight champion of the world.

If you have Netflix, the Ken Burns biography Unforgivable Blackness is available to watch instantly. It's amazing to consider how much things have changed in a century.

"Johnson in many ways is an embodiment of the African-American struggle to be truly free in this country — economically, socially and politically," said Burns. "He absolutely refused to play by the rules set by the white establishment, or even those of the black community. In that sense, he fought for freedom not just as a black man, but as an individual."

Shot Time

2009-01-17T16:41:00.008-06:00

At every ER where I've ever worked, there is a rule that must have been passed down through generations of nurses, a requirement with such authority that its justification is rarely questioned, a guideline that is so ingrained in nursing practice that only a fool would speak out against it, and then only in passing, because everyone knows that this policy is as important to nurses as their midshift break. I'm referring to the dogma that patients must remain in the ER for 20-30 minutes after receiving a tetanus shot before they are allowed to leave the premises.

Nurses will occasionally bend the "only 2 visitors in a room" rule, they might fudge on putting both of the siderails up on your stretcher, they aren't always precise about how quickly they push certain drugs through an IV, and they definitely don't reach 100% compliance when it comes to making you change into a gown prior to my evaluation, but if you try to leave too soon after receiving your tetanus shot, you'd better be prepared for a struggle, or at least a tongue-lashing. By the nurse, that is. I don't really care.

I've ordered literally thousands of tetanus shots, and not once have I needed to re-assess a patient afterwards. But most of those patients have complained at least a little bit about the wait, and many of them have become quite upset. Is it really worth it? Call me a heretic, but I say let them go. The evidence seems to support my anecdotal experience: "The risk of death from anaphylaxis following DT, Td, or tetanus toxoid (is) extraordinarily low (page 110). No cases of death...were reported through MSAEFI (the CDC's Monitoring System for Adverse Events Following Immunization) between 1979 and 1990. During that time, approximately 1.3 million doses of DT and 29 million doses of Td were distributed (page 109)."

Coo-Coo or Contra Coup

2009-01-14T02:33:00.013-06:00

I recently treated a very old and pleasantly demented gentleman who had slipped and fallen at home, sustaining a laceration to the back of the scalp. It was a witnessed fall, his second in less than a month, and there was no report of syncope or loss of consciousness. Other than the laceration, the patient was without complaint and neurologically intact, at his baseline mental status. He just wanted me to hurry up and close his wound so he could go home.

I briefly considered not ordering a CT scan; after all, his recent head scan (reflexively ordered by one of my risk-averse colleagues) was normal, he wasn't on any blood thinners, and he seemed to be OK. Apparently there are some ivory tower physicians who think we ER docs order too many imaging studies, and I heard them murmuring like a chorus in the back of my mind. Fortunately, I ignored them.

I'm certain that if I had NOT ordered a CT scan on this patient with a seemingly benign injury, the Multidisciplinary CT Scan Rationing Committee would have had a meeting with the Quality of Care Committee and they would have jointly supported my decision...even after his subdural hematoma and hemorrhagic cerebral contusions had become clinically apparent and possibly devastating. Maybe they would have even given me an award for my outstanding clinical judgment or my superior rationing of resources.

In the real world outside of academic conference rooms, nobody ever gives you a pat on the back for ordering fewer tests or practicing more cost-effective medicine. But one thing that academia and private practice have in common is that administrators in both arenas have a very low tolerance for missed or delayed diagnoses, particularly when the outcome is bad.

So we'll continue to order as many damn CT scans as we want. Personally, I'd rather order 1,000 "unnecessary" CT scans than face the question of why I didn't order the one that might have mattered.

My Beach Office

2009-01-06T12:22:00.008-06:00

Ask about our lunch specials.

Grand Rounds

2009-01-06T09:46:00.002-06:00

Grand Rounds is up, hosted this week by Dr. Edwin Leap. I hadn't contributed lately, but I happened to have a post this week which fit his topic: profit in medicine. Well done, Dr. Leap.

Four Fifty

2009-01-05T00:56:00.006-06:00

This really happened:

A young lady presented to the ER with a superficial laceration to the finger that required sutures. Maybe she also got an X-ray to rule out glass in the wound, I can't remember. When the treatment of uninsured patients is completed, our billing clerks request payment of the emergency department facility fee at the time of service. Of course we can't make them pay (unlike any other business), but we still ask for payment. The physician's fee is billed later through our billing company.

"That will be four fifty," said the billing clerk.

The young lady fished out a five dollar bill from her purse.

"No...four HUNDRED and fifty dollars."

It might as well have been $450,000,000.00.

Global Warming (or not)

2009-01-04T03:45:00.004-06:00

"(Climate change) is the biggest whopper ever sold to the public in the history of humankind." - the Huffington Post

An inescapable truth.

The $1000 Sprained Ankle

2008-12-31T09:22:00.008-06:00

Why do we love sprained ankles in the ER? Why are we establishing Fast Tracks in our EMERGENCY departments in order to expedite these cases? Why don't we want them to leave without being seen and go somewhere else?

Because we can charge you over a thousand dollars for your sprained ankle, that's why. Here's how:

ERs make money by charging facility fees which are separate from the physician's (or PA's) billing. These fees are divided into 5 levels of care depending on how complicated the visit was. A basic triage with no prescriptions might be a level 1, whereas a cardiac arrest with multiple interventions is the highest level. Points are given for each intervention such as IV placement, medication administration, discharge teaching, etc., and the total number of points is used to determine the level of care (and therefore the ER charge).

At our facility, there is a big increase from a level 2 ($225) to a level 3 ($650) facility fee. After we've given you a pain pill, sent you off to X-ray, and applied a removable plastic splint to your sprained ankle, with one click on my electronic medical record I can increase your bill by over $400 - by ordering crutches and crutch training. For some reason, crutch training is worth several points, easily enough to catapult you into level 3 territory.

So after the cost of the X-ray, pain pill, plastic splint, and crutches are added to our facility fee, and once you receive your separate bills from the Radiologist for his interpretation of your X-ray and from me for evaluating and treating you, your charges are easily over $1000 for that sprained ankle. And you haven't even picked up your prescription yet.

That's why we love sprained ankles in the ER. You don't care, your copay is only $100. But maybe you should care.

Appropriate Billing and PA Utilization

2008-12-30T07:23:00.017-06:00

I suggest that if a Physician's Assistant sees a patient independently in Fast Track or anywhere else, they should only be able to bill a maximum of 50% of the normal physician fee for that service. (UPDATE: this refers to insurance reimbursement and government programs; in a free market system, I of course believe they should be able to charge whatever the market will bear).

If a PA is directly supervised by a physician and the physician personally evaluates the patient or is physically present during the key portion of a procedure (and documents that fact) then they should be able to bill the full price. Just signing the chart is not sufficient. That is how we are required to supervise residents (some of whom already have their medical licenses and can therefore supervise PAs themselves). The requirements for supervision and documentation should not be less restrictive for PAs than for residents.

If a patient is not receiving the full service of a physician, then they (or their third-party payer) should not have to pay the full charge of a physician service. Because of the difference in training and experience, a physician's assistant does not provide the same level of care that a physician provides, even if the interaction appears to be superficially identical. So they shouldn't command the same fee.

In order to encourage physicians to still utilize and supervise PAs, I suggest reducing the liability of physicians who "supervise" essentially unsupervised PAs. After all, if the doc didn't see the patient, they shouldn't be liable (or only minimally so) for the PA's error. But PAs hardly ever make errors anyway, according to their supporters. When they are responsible for their own errors, I wager they will make even fewer.

If the theoretical numbers presented by Ten/Ten and Shadowfax are correct, a PA who was bringing in $160/hour would still bring in at least $80/hour under my system and still only cost $50/hour, so the physician groups would still make money pimping out their PAs with even less liability. Patients will have cheaper healthcare options, the costs of insurance will decrease, and the failure of the Medicare system will be delayed a bit longer.

Win/win/win. Everybody wins.

Just Say No to Fast Track

2008-12-29T12:11:00.010-06:00

I hate the concept of Fast Track in the ER.

We've had an interesting discussion about the utility of PAs in these departments, but I have found that by establishing a fast track, we perpetuate the problem of non-emergencies clogging up the ER. If you build it, they will come.

Now I understand the argument that perhaps we should be moving to a new model that embraces our new status as "acute care" facilities rather than EMERGENCY departments. Maybe we should focus on meeting the needs of whiny demanding upper respiratory infection sufferers. Neither primary care physicians nor Urgent Care facilities are easily able to do so (at least in this area) because they are shackled by the same bonds - the inability to bill adequately for these low-level cases without a facility fee. That's why emergency department administrators like these patients - by turning a 99203 into a 99283 plus a several hundred dollar facility fee, level three patients are easy money for ERs which are already open anyway.

But as a strong supporter of the concept of appropriate triage, I don't agree with streamlining the dispositions of the lowest acuity patients in the EMERGENCY department. I'll be happy to see them when I'm done with the sicker patients. If we are appropriately staffed, it probably won't take too long. If the patients with runny noses and sprained ankles are in a hurry, they can go elsewhere. If I'm too busy to see them, I'm too busy to care about them.

I wonder when Americans will see the folly of paying several hundred dollars a visit for non-emergent emergency care. Either directly via their overpriced cost-shifting "self-pay" charges or indirectly through their ever-increasing health insurance rates or their collapsing Medicare system, these patients will eventually be deterred, then another system will evolve.

The concept of Fast Track may seem like a functional solution to our current healthcare needs, but it covers up some ugly problems with our system... like putting a band-aid on a melanoma.

UPDATE: Thanks to Kevin for the link!

UPDATE: The Country Doc has similar concerns (and not only beat me to the punch, but found a couple of good articles on the topic).

Spider

2008-12-26T12:54:00.002-06:00

It's creepy.

UPDATE: There's some spoilers in the comments, so don't read them yet, just watch it.

"Where Are All the Doctors?"

2008-12-24T10:02:00.006-06:00

This is a guest post from commenter Helen:

I do have an issue. Where are all of the doctors? It seems that wherever I go there are Physician's Assistants, and the medical facilities seem to want us to think that they are doctors. What I mean by this is there is never any mention that they are not a doctor that they are a PA. They said "Deb will be in to see you soon". Deb walks in and introduces herself as Deb and never tells anyone what her title is. Many times when making an appointment we patients are never told that the PA will be seeing us. I have gone to several appointments and was never told that the professional that would be attending to my medical needs was a PA. I am a stay at home mom and my family is fully insured through my husbands employer. We are not medicaid or anything like that.

I seems to me that an appropriate use for the PA's would be for routine issues like Strep testing, pregnancy testing, UTI's, stitching patients after the Doc has seen them, diagnosing earaches all under the direct supervision of an MD. I live in Nebraska and the PA's are seeing the lions share of the patients. Many times with no physician anywhere in the building. I had to take one of my infant twins to the pediatrician for a puzzling symptom. A PA came in (without telling us her proper title). I knew something was different about her from the other physicians in the practice. There wasn't the expert presence that I usually felt with the other doctors. She did procedures and ordered expensive tests that were way off base. I came home and looked her up and I saw that she was a PA. Later I went back and saw our physician and she looked at the symptoms and gave a very reasonable explanation about what was going on. Those tests that the PA ordered were not even close to being necessary. She also left the main cause untreated.

Why are PA's running the show? Where are all of the doctors? Why are we as consumers and patients being conditioned to accept a PA as a doctor? I am in a mom's group, and most of the moms think PA's are pretty much the same as doctors. Many think the PA's are as competent and knowledgeable as doctors. Then why don't we just call the PA's doctors? When my daughter cut her finger the doc saw her and the PA came in and did the stitching. That seems like an appropriate use of a PA. There are PA's in offices where the are no medical doctors in attendance. Aren't PA's supposed to be working under direct supervision of a physician? (I know the was no doctor there because I asked).

I am not a medical professional. I am a consumer and I am at the mercy of the medical community. They tell me what they want, I have to see who they want, and often I am given no information about the type of care I am going to receive.

Helen

UPDATE: a report of more midlevel infiltration in the fields of Dentistry, Radiology, and EMS (courtesy of DocV)

Recertified

2008-12-21T10:22:00.008-06:00

I passed my board exam, thank God.

Once again, I get to claim that I am "board certified." Not by the right board, mind you, but in the dysfunctional world of emergency medicine, despite the perpetual manpower shortage that we face, the powers that be would rather not know if I could pass their test. It doesn't matter; any certification will do. When I chose this path long ago, I knew that some doors would always be closed to me, but I correctly predicted that there would be plenty of back doors to sneak in. And there are. I'm blessed to work with a great group of docs in an amazing hospital. It's a dream job.

With my solid record in the trenches insufficient to the task, the pencil-pushers are now appeased for 10 more years. As a measure of quality, I must say I found the examination lacking, but it is what it is. Just another box to check off, but not one that I feel was necessary or adequate to prove my ability. In that sense it's a hollow victory, but a victory nonetheless.

Despite the gloom of another winter, the colors look a little brighter today. Tonight, champagne.

Why PAs and NPs Don't Help

2008-12-19T14:50:00.008-06:00

I've worked with an assortment of physician assistants and nurse practitioners in various ERs, and while some of them were wonderful clinicians, I found that they weren't all that beneficial to the cause. Our group no longer employs them.

These midlevel providers are typically ~~good~~ competent at procedures, so having them sew up a laceration or drain an abscess while you crank through a few patients can be helpful in clearing the waiting room. But procedures are big money-makers in the ER, so unless the doc personally supervises the assistant, he is losing money if the PA does the procedure. Many docs commit fraud by saying they personally supervised the procedure when they really just looked at the results afterward (if that). And it's uncomfortable to me to make a paying patient settle for the services of a PA when they are paying for my services. And it's REALLY uncomfortable when their results are suboptimal.

Instead, you could use the assistants to see the minor stuff while you do the procedures. So when you get done with the laceration repair, maybe you have the PA ready to present two or three kids with colds. But when you look at the census, you see that you have a septic nursing home resident that needs to be seen NOW, and a drunk guy on a backboard that needs to be seen next. So either you are going to have to commit fraud by signing the charts of the kids with colds so you can get them out the door (and bill for their visit) without personally evaluating them, or you could make them wait until you have seen the sicker patients first before doing a quick evaluation on them (like you would do without a PA), or you could delay your evaluation of the sicker patients in order to move the meat (not likely).

Instead, you see the septic NH resident, you let the PA see the drunk guy on the backboard, and the kids with colds wait longer, like they would without a PA. But you still have to go around and see everyone anyway, and if you are a good doctor it won't take you much longer than it would have without a PA. The door to caregiver time for the minor stuff is decreased, but the time in department often isn't. And the annoying interruption factor is significantly increased. When you've got a department stacked with sick patients, the last thing you want to deal with is a PA standing there trying to present a kid with a sore throat to you.

That's why PAs and NPs don't really help.

Job Security

2008-12-19T08:20:00.003-06:00

From a recent analysis:

The number of physicians with board certification in emergency medicine is unlikely to meet the staffing needs of U.S. emergency departments in the foreseeable future, if ever. In the December issue of Academic Emergency Medicine, the investigators report finding that staffing every emergency department with board-certified emergency physicians does not appear to be feasible, given their projections for the field.

Having at least one board-certified emergency physician present in all U.S. hospital emergency departments at all times would require 40,000 physicians with such training, indicating that only 55 percent of 2005 demand was being met. Under the intermediate-scenario projection, it would not be possible to meet the goal until 2038, and under the worst-case scenario, the goal could never be met. Even if no board-certified emergency physician ever died or retired, 100 percent staffing of all emergency departments with board-certified emergency physicians would not happen for more than a decade.

via NCEMI

Quote of the Day

2008-12-16T21:26:00.002-06:00

"Why do we pay doctors big salaries to do what a nurse practitioner could easily do? Honestly I think that a nurse practitioner could easily handle what comes into an ER if they specialized in emergency medicine."

That's a bold statement.

Toxic Tampon Sydrome

2008-12-16T09:16:00.000-06:00

Most ER visits for "retained tampons" are no big deal really. Half the time there isn't even a tampon in there at all, and most of the rest are easily removed and really not as gross as one would expect.

Except this one.

As soon as I walked into the room, I knew this was the real deal. The whole room smelled like a dead rat that had been stuffed in an old gym shoe and allowed to bake on the driveway in the summer sun. It made my eyes water, and she hadn't even gotten undressed yet.

You really feel like you've done someone some good when you pull something like that out of them.

Mmmm, Bacon!

2008-12-12T12:47:00.008-06:00

It's not only delicious, but this dish actually reveals what your coronary arteries will look like after eating it. Or is that a dissecting aortic aneurysm? Hard to tell.

Serve with biscuits and gravy, and a Lipitor.

via Ace.

Snowtime in Texas

2008-12-10T18:59:00.003-06:00

The last time it snowed here was Christmas Eve 2004. That should make driving to work interesting. I've got almost an inch of fluffy white goodness on my car right now.

The Hello Kitty Hospital

2008-12-10T14:10:00.010-06:00

If I owned my own hospital, all the nurses would have to wear Hello Kitty scrubs. Taiwan beat me to the punch.

"Describing the objectives of the hospital, (the director) said: "I wish that everyone who comes here, mothers who suffer while giving birth and children who suffer from an illness, can get medical care while seeing these kitties and bring a smile to their faces, helping forget about discomfort and recover faster."

Me too, Mr. Tsai. Me too.
But my blog genderanalyzer just took a serious beating.

via Ace.

UPDATE: Not everyone likes the idea, according to Dr. Rob. I think they should have to stay in the Dora the Explorer hospital then.

TV on the Web

2008-12-08T11:08:00.004-06:00

I don't watch much TV, except for sports, but I enjoy watching Family Guy and SNL clips on the internet. While surfing around, I found this website that has quite a few full-length episodes of a variety of TV shows, so you might want to check it out. Here's another one.

I don't have any financial interest in those websites or anything else I ever recommend to you. Enjoy.

The Quickie

2008-12-06T16:22:00.011-06:00

Toward the end of a shift, an enterprising ER doc sometimes looks to take one last uncomplicated patient before going home. We call these patients "quickies."

Sometimes, what looks like a quickie really isn't, so one has to be careful.

PATIENT 1
Chief Complaint: sprained ankle (Great, send them
back!)

Nurses note: pt c/o twisted ankle and vaginal discharge for one week. (Never mind.)

PATIENT 2
Chief complaint: UTI (perfect!)

Nurses note: pt c/o burning with urination, lower abdominal pain, and vaginal discharge for one week. (Never mind.)

PATIENT 3
Chief complaint: migraine (Hmmm...migraine or pelvic, tough call)

Allergies: Toradol, Compazine, Reglan, Haldol, DHE, NSAIDS, etc. (Ka-CHUNK! back in the rack!)

PATIENT 4
Chief complaint: 6 weeks old, feverish (Maybe just a worried mom, lets look at the vitals)

Initial vital signs: Temp 98.4 (Winner!)

I enter the room to find a sick kid with a repeat temp of 102 who required a sepsis workup and a transfer to another facility, causing me to stay an hour after my shift ended. Oh well, at least the right patient got seen first.

In reality, quickies are generally not worth the effort. They aren't financially rewarding for us because of their low acuity, they aren't medically satisfying because they usually don't really need to be seen in the ER anyway, and they don't do much to decompress the waiting room since they are just as quick for the next guy. I've become more a fan of leaving on time than seeing another sore throat.

Medicare Med Refills in the ER

2008-12-04T07:04:00.005-06:00

As more and more patients become eligible for Medicare and realize that many primary care physicians are refusing to take Medicare, these patients will be forced to turn to the ER for their primary care and their med refills. And we will see them over and over and over again, which will not only clog up the ER but hasten the bankruptcy of the failing Medicare program.

But what bothers me the most are the med refills.

The Cardinal Rule

2008-12-03T12:45:00.007-06:00

photo credit

ER Tech dude: "Doc, I got a lady on the phone who wants to know if she should bring her kid in to be seen."

Me: "For what?"

ER Tech dude: "The kid drank out of a water fountain and then Mom noticed that there was a dead bird in it."

Me: "Is she sure it wasn't a bat?"

ER Tech dude: "Was it a bat, ma'am?" ... (listening) ... "Nope, it was a cardinal."

You can't make this stuff up.

Turkey Sausage Gumbo

2008-12-02T10:09:00.006-06:00

Good way to get rid of the leftovers.

1/2 cup flour
1/2 cup corn oil
one red onion
1 cup chopped celery
one green bell pepper
leftover turkey, shredded
any sausage (I only had little smokies, unfortunately)
chicken broth
cajun spice (I use Tony's)
minced garlic or garlic powder

Shred the turkey, cut the sausages into bite-size pieces, chop the veggies, set aside. Constantly whisk the flour and oil in a large cast iron skillet over medium to medium-high heat using a metal whisk until the roux becomes the color of milk chocolate (this takes around 20 minutes). Don't burn it. Turn off the heat and allow to cool a bit, whisking occasionally. Stir in some of the chicken broth, then transfer to a large pot with the rest of the broth, heat to boiling, stir well then turn down the heat to medium low. If you are going to cook the gumbo slowly over a couple of hours, just dump everything else in the pot and stir occasionally. If you want to eat quicker, then stir fry the veggies and garlic in a little oil for a couple of minutes to soften them first. Add cajun spice to taste, and add a little gumbo file (if you have any) right before serving. Spoon over steamed white rice.

ER Doc Assisted Mukasey After Collapse

2008-12-01T17:01:00.006-06:00

Next year, she'll get a better table:

Dr. Lisa Cooper, an emergency room doctor in Houston...got a chance to use her skills on U.S. Attorney General Michael Mukasey when he collapsed on Nov. 20 while giving a speech in Washington, D.C.

The Coopers...were at a Federalist Society banquet last Thursday night, where Mukasey was speaking. Mukasey collapsed at about 10:15 p.m. after talking for about 15 or 20 minutes. (Dr.) Cooper ran up to the stage from their table at the back of the room, and she treated him until paramedics arrived about 30 minutes later. She also rode with Mukasey to the hospital in the ambulance. Mukasey left the hospital the next day, and Justice Department officials characterized his illness as a fainting spell.

(Dr. Cooper) apparently was the only doctor in attendance at the banquet.

The ER is Not Burger King

2008-12-01T15:41:00.004-06:00

You wanted socialized medicine, well here it comes. Everyone gets the same burger, like it or not. You're going to have to wait, and you can't have it your way. You get a generic burger out of the pile, same as everyone else, and no, you can't have extra ketchup. You'll get used to it, onions and all.

Giving Thanks

2008-11-27T12:27:00.004-06:00

Repost from last year, with one UPDATE: Thanks also for modern technology and the blessing of perspective. (via Tasty Booze)

Here's to good friends, good health, a good meal, and a good nap.

I give thanks for the heroes who stand in harms way in the service of our country; I pray that you return home safely. I especially give thanks for those servicemen and women who have died for us, and I pray that their families know that their sacrifices are appreciated.

Thanks also for our policemen and firefighters who put their lives on the line to serve us, and especially for those who have given their all in the line of duty.

Thanks for the nurses, and the secretaries, and the paramedics, and the administrative staff, and the housekeepers, and the pharmacists, and the techs, and for all of those who are part of the healthcare team.

Thanks for all of you who have visited my blog, my family, and my friends for being a part of my life.

Thanks for my fellow bloggers who always keep things more interesting than television.

And of course a special thanks for the one who made it all possible.

Sling Tells the Story

2008-11-26T16:43:00.002-06:00

...so you don't have to. Genius.

via Tasty Booze.

Scalpel's Texas Omelette

2008-11-26T12:05:00.010-06:00

So tender you can cut it with a scalpel.
Now with EVEN MORE butter!

Red bell pepper slices
Jalapeno pepper slices
Diced ham or Canadian bacon
Bacon bits
Grated cheese
Red potato, pre-boiled
2 eggs ,well-scrambled
English muffin

Stir-fry the sliced red onions, red bell peppers, jalapeno peppers, bacon bits, and diced ham in a little butter over medium heat. Place aside on a plate and sprinkle with grated cheese. Cut the previously-boiled red potato into wedges and simmer it in butter with some sliced red onions over medium heat, turning occasionally until well-browned. Sprinkle with salt and pepper to taste, then remove onto a plate. Start toasting the muffin now because you're almost done.

Put another small dab of butter into the same Teflon-coated medium skillet and coat the skillet, still over medium heat. Pour in the egg mixture and allow to cook unmolested for 20 seconds or so, then lift up one edge of the omelette slightly and tilt the skillet so that the soupy uncooked eggs on top can flow around to contact the hot skillet underneath. This will cause one side of the omelette to be slightly thicker than the other. The thicker side will be flipped over the top.

Place the meat/veggie mixture on the thin side of the omelette and then fold the thick side carefully over the top with a spatula, trying not to tear the eggs. Cook for a few more seconds, then flip the omelette with a quick confident wrist action and cook the other side for a few more seconds. No guts, no glory when it comes to flipping omelettes. If you try to baby it, you'll mess it up.

I sprinkle the top with salt and pepper and a few shakes of Tabasco sauce. You'll notice the muffins aren't buttered. They don't need to be. They will absorb the butter from your mouth.

Enjoy.

Hats Off

2008-11-23T14:41:00.014-06:00

Two of the things that make me happy are old comic books and the writing of James Lileks. So you can imagine my great pleasure to find this treasure trove:

Night Nurse - "She's about 70 percent legs"

Night Nurse - "She may be hot, and the cape's great, but she has no powers... except maybe to wait a few minutes after the patient started jabbing the call button."

Dr. Bobbs - "Performs a fist-assisted star-ectomy"

The Unicornisaurus Rex - "With Fingers!"

and my favorite so far:

Baldy has a point: word gets out that the Bat is on the injured list, you don’t assume he’ll come after you in a one-man copter. A large, multiperson Batcopter, yes. That’s a reasonable expectation, and you make preparations. But a one-man copter? You can’t blame a guy for not seeing that one. I mean, imagine the strategy session.

Okay, boys, this is the week we knock over the barn.

Uh boss? Why a barn again?

Because that’s where the blue bag is, you idiot. Remember: everyone wear suits, so we’ll stand out in a rural setting. Then we’ll meet up right under the big metal grain chute.

Maybe It's the Cat Pics

2008-11-23T12:43:00.006-06:00

The genderanalyzer computes that there is an 81% chance that my blog is written by a woman. Another manly ER blog, MDOD, is surprisingly gender-neutral (even without cat pics).

UPDATE: Maybe if I eat some wasabi peas my blog will be as manly as GruntDoc's.

Or maybe I need to start posting about football.

via GirlyPundit

Megappendix

2008-11-22T16:29:00.006-06:00

This was the largest appendix I have ever seen. This patient had symptoms for almost a week before presenting to the ER.

CT criteria for diagnosis of appendicitis include an appendiceal diameter of greater than 6mm. This patient's appendix measured almost 2 cm in diameter, with a visible appendicolith present.

The hospital course was unremarkable.

As usual, all identifying information has been removed from the image.

Ouch!

2008-11-17T23:21:00.007-06:00

Who gets the last overtime shift? Nurse K and Monkeygirl battle it out.

Strangely addictive.

Via CollegeHumor.

Drama Signs

2008-11-17T07:41:00.016-06:00

Patients who display any of these signs probably do not have an emergency medical condition, and they will be SHOCKED to learn that all of their tests are normal.

1) They keep their eyes shut during the entire interview. Sometimes life is just too difficult to face with open eyes.

2) They flutter their eyelashes rapidly as they explain how sick they are.

3) They speak in a mousy whisper of a voice. If they tried to speak normally, the pain would be unbearable.

4) When I ask them what is the matter, they give me an exasperated look and a sigh, then they ask their spouse to tell me their story. Telling me themselves would just be too much to handle.

5) They come to the ER in a nightgown, especially if it's satin or silk.

You can bet that if any of the above patients require an IV or a blood draw, they are going to say they are a "really hard stick" requiring a "butterfly" or the "IV team," and during the procedure they are going to histrionically complain how painful it is, possibly even yelling and jerking away.

What's Wrong With America

2008-11-16T07:14:00.004-06:00

No, not the potholes. Mmmmm, I think I just had a snarkgasm.

But wait, there's more:

"Within an hour, two dozen patients checked in, five of which shared the same last name. It didn’t take long to ascertain that all five patients — children ranging in age from fourteen months to twelve years — were from the same family. A cough prompted their mother to bring them in.

That’s right — a cough. Not a fire, not some sort of freak accident that incapacitated the lot of them… a cough.

Whatever happened to Robitussin and chicken soup?"

Right on.

Grazed (twice)

2008-11-15T15:50:00.008-06:00

Chief Complaint: Leg Pain

HPI: Pt heard gunshots and ran away, felt pain in his right leg, thinks he was "grazed by a bullet." Hurts to walk on his right leg. Denies other complaints.

Exam: One cm open wound to right leg with localized swelling and tenderness. Dried blood extending inferiorly from the wound down to the ankle. Quick primary survey reveals no other wounds. Slight limp to right. Distal neurovascular status normal.

X-ray: bullet fragments noted in soft tissues of right leg. No fracture.

While cleaning the wound, I noticed a 2 mm scab on the opposite leg at approximately the same level as the primary wound. It initially appeared to be either an unrelated minor scratch or dried blood which had been transferred or splattered from the primary injury, but when it was cleaned there was clearly a tiny open wound present with mild adjacent tenderness but no swelling.

X-ray: bullet fragment noted in soft tissues of left leg. No fracture.

Morals: 1) Removing all of the dried blood from a patient is necessary to exclude occult wounds. 2) Distracting injuries can be distracting to both patient and physician.

Admittophiliacs

2008-11-11T11:03:00.006-06:00

Some people really want to be admitted to the hospital. Here are some of their more common presentations:

1) They have a flare-up of their fibromyalgia, their chronic low back pain, or their migraines, and they "just can't take it anymore." Unfortunately, in the absence of intractable vomiting or acute neurologic deficit there really isn't a good reason to admit these patients. Nowadays, patients only get admitted if there is a reasonable chance that some harm will come to them if they are sent home. "My pain is worse than usual" just doesn't qualify, and there is nothing that I can do about that. If these patients have a personal physician who compassionately agrees to admit them, I'm happy to call their doctor to arrange it. If they expect the "no doc" physician on call for the hospital (or even the partner who is covering for their personal physician) to do the same, then they are likely going to be disappointed.

2) Their gastroparesis is acting up again. They have been admitted a dozen times this year for the same problem, and they usually only last a few days at home in between admissions. There is apparently no medical regimen that will keep these patients from vomiting and allow them to function outside of the hospital, so these unfortunate patients only go home for the occasional holiday. If you think you can actually discharge them from the ER, you are mistaken. You can't fix them - they will be back in a few hours or the next day at the latest.

3) It's cold, or hot, or rainy and the smelly unkempt homeless types with chronic pancreatitis want a clean bed, a TV, 3 meals a day, and a wait staff. Oh, and another pain shot, ~~please~~ bitch.

4) She's old and lonely and feeling weak. There are no specific complaints, but she "can't go home like this." Helloooo, megaworkup.

5) He fell off a ladder and broke his _________. Unfortunately, a broken ________ is not an indication to admit an otherwise healthy adult to the hospital, even if his mother gives me a hard time over the cellphone. Sorry.

6) She's been throwing up for 3 days and feels really bad. But through the miracles of good fortune and modern medicine, all her lab tests look good and she's not throwing up anymore. Bye.

7) He's got the flu and feels really awful. Unfortunately, he's going to feel really awful for several more days whether he's in the hospital or not. Here's a work excuse.

8) He's been up for 3 days, and now he's ~~out of money for crack~~ "suicidal." Again.

9) He's still drunk from his last bender, but he's afraid he's "going to go through withdrawals." This time he's serious about quitting. Again.

Let's hear your favorites....

A Couple of Great Blogs

2008-11-11T08:05:00.003-06:00

Street Watch - Notes of a Paramedic is an old blog but it's new to me. Here is a great post on STEMI with evolving ECGs. I was going to do a post on the Autopulse but while researching it I found that Peter had not only found the same key studies that I had, but he beat me to the post by like a year and a half.

Dr. Whitecoat's favorite new blog title, Your ER Doc is unusual among our genre in that Dr. Brian Evans not only blogs without a pseudonym but he answers specific medical questions from readers. Hey man, you should charge a fee. Talk to the MDOD guys, they're floating the idea in a poll in their sidebar.

Thank You

2008-11-11T05:31:00.003-06:00

To those who served our country, know that your service is appreciated.

Wart Hog

2008-11-05T04:20:00.010-06:00

He's our president, warts and all.

Where do we sign up for our free gasoline?

He's a Cat....Flushing the Toilet

2008-11-02T14:36:00.003-06:00

Pretty self-explanatory, really.

via CollegeHumor.

Idiot of the Day

2008-10-31T13:57:00.005-05:00

via Instapundit

If I'm the one who is going to put gas in your car and pay your mortgage, how about making me a sammich?

Feline Attack!

2008-10-28T11:26:00.005-05:00

This poor young girl was viciously attacked by an unknown animal and will likely require major reconstructive surgery if she is going to survive.

There were no witnesses, and the prime suspect is still at large:

Tranquilizer Dart

2008-10-28T00:04:00.008-05:00

I have long wondered if these might be a good idea in the ER instead of the two imperfect options we currently use for involuntary sedation:

1) The long drawn-out negotiation followed (sometimes) by grudging acceptance of sedative

OR

2) The takedown followed by physical restraints and surprise manual injection of sedative into whatever meaty body part is available

If the patient is going to get a shot against his will, then a tranquilizer gun might be safer for everyone involved.
But would it work?

via CollegeHumor.

I wish the video was just a little bit longer....

Spreading the Wealth

2008-10-26T21:54:00.025-05:00

Since it appears that America is headed towards obligatory Socialism courtesy of our imminent Democrat overlords, I have come up with a plan to spread the wealth in the Emergency Department. Instead of providing excellent medical care to the relatively few patients who are fortunate to receive my outstanding personal attention, I have decided that after the election I will redistribute my efforts so that I can provide average care to a few more patients per shift. I don't mind lowering my standards for the benefit of society as a whole, and hopefully the patients who wanted superior medical treatment will be satisfied with the assembly line experience instead. If they are patriotic, they will understand.

It seems that the sickest 5% of patients are taking up entirely too much of my time, so I'm going to stop giving so much attention to those with heart attacks and strokes. I just want to make sure that everybody who is behind them with chronic back pain or poison ivy, that they've got a chance too. They shouldn't have to wait longer to be seen just because they were triaged to a lower acuity level. My attitude is that if the ER is good for folks from the bottom up, it's gonna be good for everybody.

I've decided to be more generous with narcotics as well. Instead of giving the most narcotics to those relatively few patients with severe trauma or kidney stones, I'm going to redistribute some of those opiates to patients with conditions like migraines or fibromyalgia instead. The guy with the broken femur is still going to get his shot, but he's going to have to give up a piece of his pie so that the homeless lady with a toothache can have a piece. That should be good for a bump in my Press Ganey polls. How many people really break their femurs, anyway? None in my neighborhood.

I can't wait to see how my new ideas are going to work out. After all these years of failed, misguided, and unjust policies, it's definitely time for a change in the ER. And those of us who have experienced the agony of a bad toothache can agree...we are the ones we've been waiting for. For the first time in my adult life, I'm going to be proud of my profession.

Medical Oddities

2008-10-22T02:47:00.007-05:00

Number 4 - World's largest hand

Oddee is a very interesting site. I'm hooked!

Check out the cat bomb.

A Small and an Enormous Thing

2008-10-20T11:22:00.002-05:00

"I saw some things I can’t get out of my head."

A first year med student is "incredibly freaked out" after a day at Planned Parenthood.

via Conservative Grapevine

Want a Motorcycle?

2008-10-18T07:50:00.005-05:00

Are you sure?

Be cautious of the "real nasty stuff" link at the bottom of the page. Not for the faint of heart.

I'm sort of fond of the Honda in the picture above, myself.

UTMB Hit Hard by Ike

2008-10-08T23:49:00.009-05:00

The University of Texas Medical Branch in Galveston, TX was established in 1891 and is known as the oldest medical school west of the Mississippi River. Last year, there were more than 37,000 admissions to UTMB hospitals, nearly 764,000 outpatient visits, and almost 71,000 emergency room visits. More than 12,000 faculty and staff work at UTMB’s main campus and its network of community-based clinics, making UTMB by far the biggest employer on Galveston island.

After sustaining a direct hit by Hurricane Ike, UTMB has been slow to recover and its future is in jeopardy. UTMB suffered over $700 million in damages from Ike with only $100 million covered by insurance, and given their $50 million per month payroll and impaired ability to generate income, this week university officials were warning of massive layoffs of up to 4,000 employees.

While UTMB president David Callender and UT System Chancellor Kenneth Chine said there would be no layoffs for now, they painted a very bleak financial picture for UTMB and acknowledged that jobs would be cut in the future.

The medical branch, which operates a hospital, research laboratories and a medical school, would return, but not as it was, Callender said.

Callender said that John Sealy Hospital, which supplies the bulk of the jobs at UTMB, would be reduced from a 600-bed facility to 200 beds. He also floated the idea that the hospital could be moved to a location in League City.

In my opinion, the fall of UTMB would represent the biggest tragedy of Hurricane Ike, and I hope that they can eventually survive this storm as they once survived the Great Hurricane of 1900.

Excuses

2008-10-06T09:59:00.006-05:00

Expanding on the previous post, here are some of the reasons people give for not wanting to be admitted to the hospital, along with my replies:

1) I don't want my (family member) to worry about me.
How worried will they be when they find your cold dead body in the morning?

2) I need to feed my dogs.
Who is going to feed them after you're dead? Call them.

3) I have a big presentation tomorrow.
This is what sick days are for. A heart attack is an excused absence.

4) I'm flying to ______ in the morning.
It's not safe for you to fly.

5) I can't afford to be admitted.
You can't afford not to be.

Things to Do

2008-10-06T00:31:00.004-05:00

Two patients in the aftermath of the hurricane both had problems with perspective, and both produced the exact same quote.

The first had suffered a minor laceration and was in a big hurry to get back to her un-air-conditioned powerless home.

"How long is this going to take? I've got things I need to do."

Yeah, I had a few things I needed to do too, but instead I came to work on my day off so you could get on with your life just a little bit sooner. You're welcome. And no, I don't think I can get a plastic surgeon to come put three stitches in your leg, sorry.

The second patient appeared to have suffered a stroke earlier in the day, but she refused admission. She also had some things she needed to do. I hope she finished them all.

Bill Whittle's Kidney Stone

2008-09-30T23:27:00.004-05:00

You know you're a political junkie when...

"Do you want to know what my honest-to-God first thought was when the pain got manageable enough to be able to hold a thought? I tell you: I thought of John McCain. And I’ll tell you what hit me the hardest: not his pain lasted for five years when mine lasted for four hours. But to add to that raw fear, lying in filth and knowing that those footsteps in the hall would bring not relief but more pain . . . my God! When I think about those men on those fields from Bunker Hill to Baghdad, lying there for hours, awaiting rescue and relief that often simply never came . . . I end up — and I don’t expect any of you to actually believe this — I end up grateful for those few hours."

Catnap

2008-09-30T10:18:00.003-05:00

I've got my board examination coming up very soon, so the light blogging will likely continue for a bit longer.

Scalpel or Sword?

Pause

Med Glossary, Part 5

My Take on the Health Care Crisis - Part 1

Part 2 - The Patients

Part 3 - Why Incentives are Important

Part 4 - The Safety Net

"I'm Not a Doctor...."

Why I Read Charts (of my admitted patients)

Why Freestanding ERs love EMTALA

The Texas Freestanding ER Act

Drive Through Vicodin Clinic

Make an Appointment in the ER

What is an ER For?

Video Game Poisoning

Memorial Day

Tool Time

What is an ER?

Quote of the Year (So Far)

Comedy of Errors

A Lesson for the LA Lakers

Happy Mother's Day

How Would You Respond?

Quote of the Day

Starting the Hypothermia Protocol

The John Galt Memorial Freestanding Emergency Center

On Vacation

Misunderstanding

Self-censoring the Medical Record

Night Nurse

Doomed to Failure

On Needing Eyeglasses

A Pitibull Situation in Chicago

The Obesity Epidemic

Duck Hunt Made Easy

Get Rid of Your Medical Insurance

Symbolism and Irony

I am the Wolf

Tough Guys

The Stinger

Quote of the Day

Super Bowl Stadium Snack Tray

Four Chord Songs

The Uselessness of the TIMI Risk Score

Thank You President Bush

Rationing AICDs in Canada

Jack Johnson

Shot Time

Coo-Coo or Contra Coup

My Beach Office

Grand Rounds

Four Fifty

Global Warming (or not)

The $1000 Sprained Ankle

Appropriate Billing and PA Utilization

Just Say No to Fast Track

Spider

"Where Are All the Doctors?"

Recertified

Why PAs and NPs Don't Help

Job Security

Quote of the Day

Toxic Tampon Sydrome

Mmmm, Bacon!

Snowtime in Texas

The Hello Kitty Hospital

TV on the Web

The Quickie

Medicare Med Refills in the ER

The Cardinal Rule

Turkey Sausage Gumbo

ER Doc Assisted Mukasey After Collapse

The ER is Not Burger King

Giving Thanks

Sling Tells the Story

Scalpel's Texas Omelette

More Emergency Medicine Links I like

Hats Off

Maybe It's the Cat Pics

Megappendix